CHO Specialty Referral Info

Edit 1 …

CHO Specialty Clinic
Complete CHO “Patient Evaluation Form” and fax with appt. notes/labs/Xrays etc.
Complete and fax CCHP Prior Authorization form
(313-6058)
Complete CCS application/request for service form, fax to CCS (313-6115)
Number to call for appt. AFTER authorization is obtained
(if TO can make appt immediately)
AUDIOLOGY

YES

Fax: 510-
450-5631
 YES (if HO)
YES (if TO, GO, H9, AO)
(Hearing loss is CCS eligible)
Phone: 510- 428-3344
CARDIOLOGY
YES

Fax: 510-
428-3381
 YES (if HO)
YES (if TO, GO, H9, AO)
(Most cardiac diseases, primary HTN, cardiac dysrhythmias are CCS eligible)

Phone: 510-428-3380
CHILD DEVELOP-MENT/
BEHAVIORAL PEDIATRICS
NO complete ‘Intake Referral Form” specific to this clinic only
Fax: 510-
601-3912
*specify if family is Spanish speaking.

YES

(if GO, H9, HO, A0)
NO

(developmental delays and behavioral issues are NOT CCS eligible)
 D. O’Hara Intake Coordinator

510-428-3351 X4353

(packet will be mailed to family to complete & mail back before appt can be scheduled)

CRANIO-FACIAL

NOT REQUIRED BUT MAY BE USED-call before faxing any information

Fax: 510-
601-3989
 YES (HO)

YES (TO, GO, H9, AO) (cleft lip/palate, other congenital anomalies or ‘severely disfiguring’ conditions)
 Valerie or Gloria 510- 428-3150
(family will be contacted after review of referral by medical staff)
EEG
NO
Fax an rx or EEG requisition with pertinent medical info to: 510-601-3974
NO
no P/A needed for GO, HO, H9
 YES

(if CCS eligible condition)
*seizure d/o is not CCS eligible

510-428-3209 or
510-428-3590
ENDOCRINE
YES
Fax: 510- 450-5614
(include growth chart with referral)

 YES
(if HO, or if not a CCS eligible condition)
YES (examples of CCS eligible conditions diabetes, thyroid, pituitary, growth hormone deficiency)
510-428-3654
ENT
YES
Fax: 510-
450-5613
 YES
(if HO, or not CCS eligible)
 NO
(tends not to be CCS eligible)
510-
428-3233
EYE CLINIC (OPTHAM-OLOGY)
YES
Fax: 510-
587-7172
 NO
(for GO, HO, H9 no P/A needed)

YES (if AO)
 YES
(if CCS eligible, examples: ROP, strabismus requiring surgery, cataract, glaucoma, retinal detachment,, ptosis, congenital eye anomalies)
510-
428-3226
(appts.)
510-
428-3050
(clinic)
*5275 Claremont Ave.
GASTRO-ENTEROLORY
YES
Fax: 510-
450-5813
 YES
(for HO, or if not CCS eligible dx)
 YES
(if CCS eligible: liver failure, pancreatitis, peptic ulcer, congenital anomalies)
510-
428-3058
HEM/ONC
YES
Hemophilia & general hematology: ask for Jim Rydell RN
Sickle cell: ask for Pat Shields RN
Oncology
Provider usually calls on-call MD

Fax: 510- 601-3916
 YES
(if HO)
YES
(TO, GO, H9, AO)
(CCS eligible:
hemophilia, sickle cell, hemolytic anemias, coagulation disorders, platelet disorders, all malignant neoplasms are CCS eligible)


510-428-3372
MEDICAL GENETICS
YES
510-450-5874
*note if family is Spanish speaking
 YES
NO
(generally)
‘syndromes’ are not CCS eligible
510-428-3550
Clinic staff will contact family with appointment
MRI
NO
Complete ‘MRI Patient Screening’ & ‘MRI Safety Questionnaire’ and fax to: 510-450-5814)
 NO

(only if anesthesia
is needed)
 YES

(for CCs eligible conditions only)
510-428-3410
NEPHROLOGY
YES
Fax: 510- 450-5850
 YES
(if HO, or not CCS eligible)
 YES
(if CCS eligible: reflux grade II or >, hydronephrosis, obstructive uropathies)
510-
428-3335
NEUROLOGY
YES
Fax: 510- 601-3974
 YES
(if HO, or not CCS eligible)
*seizure disorder is not generally CCS eligible
YES
(if CCS eligible: brain tumor, tuberous sclerosis, some cerebral palsy, status epilepticus)
510-
428-3590
NEURO-SURGERY
YES
Fax: 510- 597-7034
 YES (if ‘HO’ or not CCS eligible dx)
 YES
(If CCS eligible: congenital spine anomalies, spina bifida, hydrocephalus, craniosynostosis, skull fracure)
510-
428-3319
ORTHO-PEDICS
YES
Fax: 510- 601-3904
 YES
(if ‘HO’ or not CCS eligible)
 YES
(If CCS eligible: club foot, JRA, dystrophies, myasthenias, scoliosis > 20 degrees)
510-
428-3238
PEDI REHAB
YES
Fax: 510-
450-5821

*if requesting PT/OT write rx with dx.
 YES
(if ‘HO’ or not CCS eligible diagnosis)
 YES
(If CCS eligible: muscular dystrophy, cerebral palsy, any traumatic injuries or conditions that require physiatrist intervention)

510-428-3655
(after appt. scheduled, clinic will generate client specific form to be completed by referring provider
PULMONARY
YES
Fax: 510-
597-7154
 YES
(if ‘HO’ or not CCS eligible dx)
 YES
(if CCS eligible: cystic fibrosis, CLD, respiratory failure, BPD)
510-428-3305
RHEUMA-TOLOGY

Fax: 510-
450-5678
 YES (If ‘HO’ or not CCS eligible dx)
 YES (if CCS eligible: lupus, JRA, scleroderma)
510-428-3304
SURGERY/
UROLOGY

PEDIATRIC SURGICAL ASSOCIATES





Fax: 510-
428-3405
 YES
(unilateral
undescended testicle, inguinal/umb. hernias are not CCS eligible)
 YES

(if CCS eligible: reflux grade II or >, traumatic injuries)

510-428-3022